The impact of communication skills training in the management of paediatric HIV : examining the process of designing, implementing and evaluating a communication skills training programme for adherence counsellors in the South African context.

摘要

This study examines the design, implementation and evaluation of a communication skills training programme forudadherence counsellors in a paediatric HIV clinic. Effective communication is a pre-requisite skill for any counsellingudinteraction. For both prevention and treatment, counselling is a critical component of the healthcare team response toudthe HIV epidemic. Given the shortages of healthcare workers in sub-Saharan Africa, task-shifting of the counsellingudrole to less-trained cadres of workers is commonplace. In the multilingual, multicultural South African context, taskshiftingudcoupled with the complexity of the message in paediatric HIV presents enormous challenges. In-serviceudsupport for counsellors is lacking. Counsellor burn-out and fatigue is commonplace affecting the quality ofudcounselling interactions.udMeasuring the quality of communication in a multilingual context poses ethical and methodological challenges and isuda neglected area of research. Traditional communication and counselling assessments appear to be largely taxonomic;udlack cultural and linguistic sensitivity; and fail to acknowledge communication as a dynamic, two-way process.udMindful of these issues, this study utilized a non-taxonomic approach.udVerbal and non-verbal communication was analysed before and after the implementation of in-service training whichudwas tailored to the specific research context. The training comprised a two day multidisciplinary team workshopudfollowed by individual training. This consisted of video feedback and analysis of counsellors’ own sessions and wasudattended by four counsellors. Results were recorded over an eighteen month period. Twenty-two consultationsudbetween counsellors and caregivers were video-recorded, transcribed verbatim and analysed using a hybridized formudof linguistic analysis. Findings that demonstrated consensus, substantiation and cross-consultation occurrence wereudtriangulated with thematically analysed interview data, patient questionnaires and researcher reflections. Theseudmethods are more sensitive to process than checklist approaches and individualised, complex dynamics emerged.udCommunication barriers and facilitators were identified before training. Variations in communicative competenceudbetween counsellors appeared to be unrelated to prior training. After training, counsellors asked more open-endedudquestions, encouraged caregivers more, provided simpler explanations of treatment regimens and checkedudunderstanding more effectively. In response, caregivers initiated more questions. These findings suggest thatudcommunication training improves treatment literacy and results in interactions that are more patient-centered. Despiteudthis evidence, the results suggest limitations to the impact of communication training given the lack of agency ofudwomen in South Africa. Interactions included frank and open discussion about cultural beliefs. However, this benefitudmay be lost due to poor healthcare team cohesion. In their roles as mothers and caregivers themselves, counsellors areudeffective patient advocates and bring their own lifeworld experience to the counselling interaction. These sharedudstories are testimonies to the resilience of women living in poverty. Whilst allowing for greater exploration ofudpatients’ cultural beliefs and explanatory models, communication training has limited impact in assisting counsellorsudwith dealing with issues such as disclosure, non-adherence and scepticism about biomedicine. Results indicate conflictudbetween patient-centeredness and perceived desired medical outcomes. Caregivers and counsellors appeared to engageudin ritualistic dialogue when discussing certain topics suggesting that a shared lifeworld between caregiver andudcounsellor is insufficient to overcome barriers from the meso (institutional) and macro (broader socio-political)udcontext.udAn awareness of the impact of context is critical to our understanding of communication in a clinical setting. Theudresults from this research have implications for the role of the counsellor within a multidisciplinary team and establishuda need for communication specialists to work in a clinical setting within the HIV epidemic.